SEC Form 3
| FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 02/06/2018 | 3. Issuer Name and Ticker or Trading Symbol SAFETY INSURANCE GROUP INC [ SAFT ] | |||||||||||||
| 4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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| Table I - Non-Derivative Securities Beneficially Owned | |||
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| 1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
| Common Stock | 1,537,233 | I | See Footnotes(1)(2)(3) |
| Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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| 1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
| Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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| Explanation of Responses: |
| 1. This Form 3 is being jointly filed by SRB Corporation, a Massachusetts corporation ("SRB"), The Plymouth Rock Company Incorporated, a Massachusetts corporation ("PRC"), and Palisades Safety and Insurance Association, a New Jersey reciprocal insurance exchange ("PSIA"), and each shall be deemed a Reporting Person. SRB is a direct, wholly-owned subsidiwy of PRC and acts as investment manager to each of PRC and PSIA, and, in such capacity, may be deemed to have voting and dispositive power over the shares of Common Stock reported on this Form 3. SRB disclaims beneficial ownership of the shares of Common Stock reported on this Form 3, and this report shall not be deemed an admission that SRB is a beneficial owner of such shares for purposes of Section 16 or for any other purpose. The Reporting Persons are making this single joint filing because they may be deemed a "group" within the meaning of Section 13(d)(3) of the Securities Act of 1934, as amended. |
| 2. PRC holds 539,296 of the shares of Common Stock reported on this Form 3. PRC includes the accounts of the following entities: Plymouth Rock Security Corporation, a Massachusetts security corporation ("PRSC"); Plymouth Rock Assurance Corporation, a Massachusetts corporation ("PRAC"); Pilgrim Insurance Company, a Massachusetts corporation; ("PIC"); Mt. Washington Assurance Corporation, a New Hampshire corporation; Bunker Hill Insurance Company, a Massachusetts corporation ("BHIC"); Bunker Hill Insurance Casualty Company, a Massachusetts corporation ("BHICC"); Bunker Hill Preferred Insurance Company, a Massachusetts corporation ("BHPREFIC"); Bunker Hill Property Insurance Company, a Massachusetts corporation ("BHPIC"); and Bunker Hill Security Insurance Company, a Massachusetts corporation ("BHSIC"). PRSC, PRAC, and BHIC are direct wholly-owned subsidiaries of PRC. PIC is a direct wholly-owned subsidiary of SRB. |
| 3. PSIA holds 997,937 of the shares of Common Stock reported on this Form 3. PSIA includes the accounts of High Point Safety and lnsurance Company, a New Jersey corporation ("HPSIC"); High Point Property and Casualty Insurance Company, a New Jersey corporation ("HPPCIC"); and High Point Preferred Insurance Company, a New Jersey corporation ("HPPIC"); Palisades Insurance Company, a New Jersey corporation ("PICNJ"); Twin Lights Insurance Company , a New Jersey corporation ("TLIC"); and Teachers Auto Insurance Company of New Jersey, a New Jersey corporation ("TAIC"). HPSIC, HPPIC, TLIC, and TAIC are direct wholly-owned subsidiaries of HPPCIC, which is a direct wholly-owned subsidiary of PSIA, as is PICNJ. |
| Remarks: |
| Footnote #1 continued: This joint filing shall not, however, be deemed an affirmation that a group exists among the Reporting Persons for the purposes of the Securities Exchange Act of 1934 or for any other purpose and each Reporting Person expressly disclaims beneficial ownership of any securities beneficially owned by any other person. Footnote #2 continued: BHICC, BHPREFIC, BHPIC, and BHSIC are direct wholly-owned subsidiaries of BHIC. PRC disclaims beneficial ownership of the shares of Common Stock reported on this Form 3 except to the extent of its pecuniary interst therein, and this report shall not be deemed an admission that PRC is a beneficial owner of such shares for purposes of Section 16 or for any other purpose. Footnote #3 continued: PSIA disclaims beneficial ownership of the shares of Common Stock reported on this Form 3 except to the extent of its pecuniary interest therein, and this report shall not be deemed an admission that PSIA is a beneficial owner of such shares for purposes of Section 16 or for any other purposes. |
| /s/ Frederick C. Childs for SRB Corporation | 02/13/2018 | |
| /s/ Colleen Granahan for The Plymouth Rock Company Incorporated | 02/13/2018 | |
| /s/ Ed Fernandez for Palisades Safety and Insurance Association by Plymouth Rock Management Company of New Jersey, its Attorney-in-Fact | 02/13/2018 | |
| ** Signature of Reporting Person | Date | |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
| * If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
| ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. | ||